Dear Esteemed Colleague,
We are proud and delighted to welcome you to the most happening city of Hyderabad for the 17th
Asian Musculoskeletal Conference. It is being held in conjunction with International Skeletal Society
Reach Out Program (ISROP) to be held from March 14-15, 2015 at Hyderabad International
Convention Centre (HICC), Hyderabad. Musculoskeletal Society (MSS), India was founded in
Hyderabad in the year 2012 with 12 founder members and the present membership is around 100.
Musculoskeletal Society, India is honored and privileged to host the AMS conference in Hyderabad.
Hyderabad is a 400 year old city and has been a pride of place for its Mogul background, rich cultural
heritage and its hospitality. In recent years, it has attained an eminent position as a tourism hub
amongst the world travelers. Hyderabad is known for itspearls,lakes andcuisine. In spite of
tremendous advancements in the field of Information Technology,pharmaceuticals, Bio-technology
and Medical education, it has retained its old Mogul charm. Hyderabad is now being rated as an
excellent tourist attraction with Charminar, Choumallah Palace, Falaknama palace, various Gardens,
Laser shows, Golconda Fort, Salar Jung museum, Ramoji Film City, Snow World and the largest 3D
IMAX theatre. Hyderabad is also known for the tallest monolith Buddha statue in the midst of
Hussain sagar Lake.
Elaborate arrangements are in progress to organize the conference and to make it memorable. World
renowned and distinguished Radiologists practicing Musculoskeletal Radiology,from abroad and
Indiawill participate and lecture on recent advances. The highlights of the conference include an
excellent scientific program, oral presentations, scientific exhibitions, awards, variety of social and
cultural evenings and state of the art medical equipment on display at the trade exhibition.
We look forward to receiving you and your families with folded hands.
Prof.Kakarla Subbarao
Chairman
Prof. Yang Seoug Oh
President Asian
Musculoskeletal Society
Dr.Kundur Prabhakar Reddy
Organizing Secretary
Welcome to Hyderabad
Dear colleagues,
It gives me great pleasure to welcome you to Hyderabad to participate in 17th Asian
Musculo-Skeletal Society conference in collaboration with international skeletal society
reach out program to be held from March 14-15 at Hyderabad International Convention
centre, Hyderabad.
The Asian Musculo-skeletal society conference is being conducted first time in India
and organized by Musculo-skeletal society, India, which was formed in 2012. The Asian
Musculo-skeletal society has been continuously growing, expanding and ever evolving.
An excellent scientific and educational program is planned to further your knowledge
to stay at the cutting edge of practice.
The scientific program will address wide spectrum of topics in Musculo-skeletal
Radiology and Imaging. The highlights of conference include recent advances, orations,
workshops, guest lectures, refresher courses, scientific posters both conventional &
electronic, scientific and technical exhibits. In addition there will be ‘’AMS best paper
award session’’ besides Best paper award session for the residents by Musculo-skeletal
society, India. Image interpretation session, meet the professor sessions, display of
“Case of the Day” images in Radiology quiz also planned.
The faculty includes eminent radiologists from Asian Musculo-skeletal society,
International Skeletal society and Musculo-skeletal society, India.
I once again welcome you all to participate in this global scientific forum and actively
discuss issues in the Musculo-skeletal Radiology and Imaging
Looking forward to welcome you to Hyderabad in 2015
Prof. T. Mandapal
Chairman, Scientific committee
17TH Asian Musculoskeletal Society Annual Congress
In Conjunction with International Skeletal Society Reach out Programme
(ISSROP)
Organized by
Musculoskeletal Society, India
14th & 15th March 2015, HICC, Hyderabad
DAY-1 - 14th MARCH (SATURDAY)
Hall -1
AMS & MSS Joint Session
8.15-8.30
Opening Ceremony
Moderators – Dr.K.Prabhakar Reddy &
Dr.T.Mandapal
8.308.50
Sclerosing Skeletal Dysplasias
8.509.10
Hybrid imaging applications in
Musculoskeletal Disorders
9.109.30
Vertebroplasty: Current status, future
directions and controversies
9.3010.15
Prof. Kakarla Subbarao Oration - A
Testimony to Changing times Tribute from
Dr.Varaprasad Vemuri - “Pitfalls in
musculoskeletal MR imaging”
Kakarla
Subbarao
Seoung-Oh
Yang
Peter L Munk
Wilfred Peh
10.15-10.30 TEA BREAK
10.3011.30
AMS/ISS BEST PAPER AWARD
PRESENTATIONS
11.3012.15
Tummala Madhusudana Rao Endowment
Oration – “3D MR Neurography of
Lumbosacral plexus”
12.151.05
Prof. Virinder Mohan Gold Medal Award for Best Post
Graduate Paper in Conventional Radiology
Avaneesh
Chhabra
1.051.25
FUTURE MSK MEETINGS
(Nuttaya Pattamapaspong)
ESSR Congress in York, UK 2015
Tuhin Sikdar
ISS meeting in Maui, USA 2015
Peter L Munk
Joint 18th AMS-AGSSR meeting in Kuwait
2016
MSS India meeting 2016
Amr Galal
MSS
1.25-2.10 LUNCH
SPINE
Moderators – Sri Andreani Utomo & Dr.Chidambarnathan
2.102.30
Imaging of tuberculous spondylodiscitis
Sri Andreani
Utomo
2.302.50
Imaging of primary bone tumours of the
spine
Sujata Patnaik
2.503.10
Characterising spine marrow lesions
using diffusion-weighted MRI
3.103.30
Lumbar disc: protrusion, extrusion and
confusion
3.303.50
Imaging of the facet joints
Hirak Ray
Choudhury
J Jagan Mohan
Reddy
Lalitha Palle
3.50-4.10 TEA BREAK
SPINE
4.104.30
Moderator – Dr.Nuttaya Pattamapaspong &
Dr.Kishore.L.T
Imaging of seronegative
spondyloarthropathies
Sandeep
Velchetti
4.304.50
Role of US in the neonatal spine
4.505.10
Imaging of extradural lesions of the spine
5.106.00
Film Reading Session
TLN Praveen
Jian
Ling Cui
Harun Gupta
7.00-9.00 p.m. Banquet at Poolside Lawns of Hotel Novotel
DAY-1 - 14th MARCH (SATURDAY)
1.25-2.10 LUNCH
WCG Peh,
M J Kransdorf,
G Buirski,
C Martinoli
2.10-5.10
HALL 3, 4, 5: ISS ROP Teaching Programme :
Hall 3
Imaging of Musculoskeletal Tumors 1
MJ Kransdorf
Hall 4
Radiographic approach to assessment of
Arthritis
G Buirski
Hall 5
Musculoskeletal Ultrasound: an overview
C Martinoli
DAY-1 - 14th MARCH (SATURDAY)
HALL-6
MISCELLANEOUS - HALL-6
Moderators – Dr.Shigeru Ehara & Dr.Jayraj Govindraj
2.10Imaging of articular cartilage: basic to advanced
2.30
Khalid Al-Ismail
2.302.50
Quantitative Imaging Analysis of Rheumatrid Arthritis Tamotsu
Kamishima
2.503.10
High-resolution US approach to arthritis
S Narayan
3.103.30
Imaging approach to paediatric metabolic disease
3.303.45
Diagnosis of subtle bone erosions in the digital
Environment
Rakhee
Paruchuri
Shigeru Ehara
3.50-4.10 TEA BREAK
MISCELLANEOUS
Moderators – Dr.Xinaguang Cheng & Dr.N.Eshwar Chandra
4.104.30
Imaging of metallic implants in bone
4.304.50
4.505.1
0
MRI of brachial plexopathies
Profile of musculoskeletal injuries in wrestlers
Xiaoguang Cheng
Jyoti S Panwar
Shalini Agarwal
DAY-2 - 15th MARCH (SUNDAY)
Hall -1
HIP
Moderators – Dr.Remide Arkun &
Dr.Abhimanyau Kelkar
8.40-9.00
MRI of femoro-acetabular
impingement: current concepts
Remide
Arkun
9.00-9.20
Athletic pupulgia, “sports
hernia” and anterior pelvic pain
Seng Choe
Tham
9.20-9.40
Imaging evaluation of
degenerative disease of the hip
Anitha
Mandava
9.4010.00
Imaging of the hip joint in
children
NLN Moorthy
10.00-10.15 TEA BREAK
KNEE
Moderators – Dr.Suphaneewan
Jaovisidha & Dr.K.J.Reddy
10.1510.35
MRI of the meniscus
10.3510.55
MRI of cruciate and collateral
ligaments
Hemanth
Patel
10.5511.15
Imaging of the posterolateral
corner
Malini
Lawande
Imaging of patellar instability
Anupama
Patil
11.1511.35
11.3511.55
MRI of knee arthrosis
Richa Arora
Bambang
Budyatmoko
11.5512.15
Imaging knee injury in children
Suphaneewan
Jaovisidha
12.1512.35
High-resolution US in knee joint
swelling
Jyotsna Sen
12.3512.55
Imaging of posterior tibial
dysfunction
Sheikh
Adnan
12.55-1.40 LUNCH
ANKLE & FOOT Moderator – Dr.Lisa L S Wong
1.40-2.00
MRI of ankle ligaments
Kunwarpal
Singh
2.00-2.20
MRI of impingement syndromes
around the ankle
Kulvinder
Singh
2.20-2.40
US of tendon lesions of the ankle and foot
Lisa LS Wong
2.40-3.00
Raj Negi
MRI of heel pain
3.00-3.20
Role of CT in ankle and foot problems
Nuttaya Pattamapasong
3.20-3.40
approach
Infections and inflammations of the foot: multimodality
Rammohan Vadapalli
3.40-4.00 TEA BREAK
4.00-4.20
Imaging of sesamoids and accessory ossicles of the
foot
Sanjeewa Munasinghe
4.20-4.40
Imaging of talar osteochondral lesions
Mahesh Prakash
4.40-5.00
Infections of Skull Bones
Virinder Mohan
5.00-5.20
Avulsion Injuries
Pramod Kolwadkar
DAY- 2 - 15th MARCH (SUNDAY)
Halls - 3, 4, 5, 6 - Workshops - 7.30 - 8.30
Hall - 3
7.30-8.00
ULTRASOUND OF HAND AND WRIST
Mihra S Taljanovic
8.00-8.30
ULTRASOUND IMAGING OF ELBOW – TECHNIQUE AND
EVALUATION
P K Srivastava
Hall - 4
7:30 – 8:00 ULTRASOUND OF THE KNEE - WHAT TO LOOK FOR?
Marina Obradov
8:00 – 8:30 ULTRASOUND OF ANKLE- NORMAL AND ABNORMAL
Ashwin Lawande
Hall - 5
7:30 – 8:30 MUSCULOSKELETAL INTERVENTIONS
Harun Guptha,
Hema Nalini
Hall - 6
7:30 – 8:00 ULTRASOUND OF BRACHIAL PLEXUS
Carlos Martinoli
8:00 –
8.30
IMAGING OF LOWER LIMB NERVES
Srinadh Boppana
DAY- 2 - 15th MARCH (SUNDAY)
INTERVENTIONS
HALL-6
Moderator – Dr.Ian YY Tsou
8.40- 9.00
Imaging-guided biopsy of spinal lesions
Hong Chou
9.00-9.20
Cervical disc nucleoplasty
Ian YY Tsou
9.20-9.40
Foraminal epdiural injections for low back
pain
Tuhin Sikdar
9.40-10.00
US-guided injections in tendons: update
10.00-10.15 TEA BREAK
Marina Obradov
SHOULDER
Moderator
– Dr.Heung
SIK Kang
10.15-10.35
MRI of labraligamentous complex
Swee Tian Quek
10.35-10.55
US of the glenoid labrum
Srinadh
Boppana/Gupta
10.55-11.15
MRI of rotator cuff lesions
Sunitha Linga
Reddy
11.15-11.35
MRI and US of biceps tendon abnormalities
Kyung Jin Suh
MRI of the rotator cuff interval
11.35-11.55
11.55-12.15
MRI of SLAP lesions
12.15-12.35
Role of US in suprascapular neuropathy
12.35-12.55
Role of MRI in the post-operative shoulder
Tummala
Madhusudana Rao
Abhimanyu
Kelkar
Joban Babhulkar
Ankur Shah
12.55-1.40 LUNCH
ELBOW, WRIST and HAND
Moderator
Dr.Kunihiko Fukuda
1.40-2.00
MRI of the elbow injuries
Mihra Taljanovic
2.00-2.20
MRI of the elbow joint in inflammatory
arthritis
Swati Parchane
2.20-2.40
US of the elbow
Niraj Dubey
2.40-3.00
Tennis elbow: imaging, differential diagnosis
and Injections
Hema Nalini
Choudur
3.00-3.20
MRI of wrist tendons
Sanjay Desai
3.20-3.40
MRI of extrinsic and intrinsic ligaments of the
wrist
Srikanth
Narayanaswamy
3.40-4.00 TEA BREAK
4.00-4.20
Imaging of SLAC wrist
4.20-4.40
Psoriatic arthritis and erosive arthritis
Kunihiko Fukuda
4.40-5.00
Percutaneous management of Osteoid
Osteoma
N.V. Chalapathi
Rao
5.00-5.20
MRI Imaging of Finger
5.20-5.40 pm VALEDICTORY FUNCTION
VN Varaprasad
Sanjay Desai
Imaging evaluation of degenerative disease of the hip
Dr. Anitha Mandava, MBBS, DMRD, DNB.
Head of the Department,
Department of Radiology,
Central Hospital, South Central Railway,
Andhra Pradesh, India.
Abstract:
Osteoarthritis (OA) is a chronic, debilitating joint disease characterized by
degenerative changes to the bones, cartilage, menisci, ligaments, and synovial tissue.
Worldwide, osteoarthritis is the most common form of arthritis. Although the incidence
of osteoarthritis increases with age, the condition is not a normal part of the aging
process.
The precise etiology of osteoarthritis is unknown, but biochemical and
biomechanical factors are likely to be important in the etiology and pathogenesis.
Biomechanical factors associated with osteoarthritis include obesity, muscle weakness
and neurologic dysfunction. Sequelae from childhood diseases (eg: Developmental
dysplasia, Perthes disease, Slipped capital femoral epiphysis, Juvenile rheumatoid
arthritis), infection, trauma, osteonecrosis, inflammatory arthritis, idiopathic arthritic,
femoral acetabular Impingement (FAI) etc may cause early onset of degenerative
disease of the hip.
The cardinal symptom of osteoarthritis is pain that worsens during activity and
improves with rest. The pain is usually described as being in the groin or thigh for
degenerative joint disease of the hip.
Radiographs may be useful in confirming the diagnosis of osteoarthritis,
assessing the severity of the disease, reassuring the patient and excluding other
pathologic conditions. The radiographic hallmarks of primary osteoarthritis include
nonuniform joint space loss, osteophyte formation, cyst formation and subchondral
sclerosis; however, in early osteoarthritis, minimal nonuniform joint space narrowing
may be the only radiographic finding. The main shortcomings of radiography are its
insensitivity to change and its lack of soft-tissue depiction.
AP views of the pelvis can be used to assess arthritic changes in the hips as
well as the sacroiliac joints. Changes associated with the hip include superolateral joint
space narrowing with subchondral sclerosis. The superolateral portion of the joint is the
weight-bearing portion. Cystic changes can occur, and the femoral head can appear to
be irregular.
The osseous detail is better appreciated with CT scan. MRI can be helpful in
evaluating cartilage loss and also in diagnosing additional associated pathologies like
post-traumatic injuries, malignancy, neural foraminal impingement, infectious process.
Ultrasonography has limited role and can be helpful in diagnosing cystic changes in the
soft tissue about the joints but is not useful in the initial diagnosis of osteoarthritis.
Conclusion: The diagnosis of degenerative disease of the hip (osteoarthritis) is based
primarily on the history and physical examination while radiographic findings,
including asymmetric joint space narrowing, subchondral sclerosis, osteophyte
formation, subluxation and distribution patterns of osteoarthritic changes are helpful in
confirming the diagnosis and assessing the progression of the disease. Radiography is
primarily useful for the assessment of bony structures, US for ligaments and the
synovium and MRI permits visualization of articular cartilage, intraarticular structures
and pathologies.
MR in knee osteoarthritis
Bambang Budyatmoko MD,
RS Premier Jatinegara
Dept Of Radiology
Faculty of Medicine University of Indonesia
JL Diponegoro 71-Jakarta 10430
Indonesia.
Abstract:
Osteo arthritis or degenerative joint disease is the most common of the various
articular disorder.
Osteoarthritis is slowly
evolving articular disease ,characterized by
biochemical,histological and physical abnormalities of cartilage
Osteoarthritis is common progressive disorder of movable joint characterized by
deterioration and abrasion of articular cartilage and by new bone formation at joint
surfaces and margin .
Men and women are almost equally affected and clinically characterized by
pain,limitation of motion and later deformity and slowly progressive disability mostly
at the age more than 45 year.
Pathogenesis of osteoarthritis is articular cartilage matrix metabolism . The function of
articular cartilage include mechanical support and congruous joint motion.
The capacity of the cartilage proteoglycan for holding water provide the hydration
neccesarry to maintain elastic resistance to compression and help to generate
lubricating abilities
The earliest biochemical changes are increased water content,decreased proteoglycan
and latter collagen disruption.
With cartilage destruction,provide stimulus for blood vessel growth in the subchondral
bone,which become eburnated and sclerotic. Leading to spur formation
Osteoarthritis is disease of the joint that affects of all weight bearing component ,
bone,cartilage , meniscus,ligament
Magnetic resonance Imaging (MRI) provide excellent soft tissue contrast and its
capable of evaluating the soft tissue and bonny structures of the knee osteoarthritis in
multiple image planes and sequences which significance advantages over other
modality
Image guided biopsy of spinal lesions
Chou Hong
Consultant Radiologist
Department of Diagnostic Radiology
Khoo Teck Puat Hospital, Singapore
Abstract:
Image guided biopsy of spinal lesions has become a routine method of obtaining tissue
for diagnosis of neoplastic as well as infectious disease. It has proven to be accurate,
safe and well tolerated in experienced hands with CT as the imaging modality of choice.
Good knowledge of anatomy and precise needling technique is important to avoid
potential complications. With the proper approach, awareness of surrounding vital
structures and use of appropriate equipment, the procedure can be performed safely
and with adequate yield.
When properly performed, image guided biopsy of spinal lesions serve to guide
clinicians in the management of spondylodiscitis as well as malignancies such as
myeloma and metastatic disease.
Ultrasound of glenoid labrum
Ultrasound guided glenohumeral joint injection and
hydrodistension
Dr Harun Gupta MBBS,MD,DNB,MRCP(UK),FRCR(UK)
Department of MSK Radiology
Leeds Teaching Hospitals,
Leeds General Infirmary,
Leeds LS1 3EX, UK
Abstract:
Labral pathology is usually post traumatic and is an important cause of shoulder
instability. Majority of lesions involve the anterior part of the labrum as within
instabilities, anterior instability predominates. MRI with intra-articular contrast (MR
Arthrography) is the modality of choice for evaluating patients with shoulder instability
or internal joint derangement. Ultrasound can be used in such patients for assessing the
integrity of the rotator cuff. However, there has also been an interest in evaluation of
labrum with ultrasound due to its wide availability, lesser cost and in cases of
contraindication to MRI.
US features which confirm labral pathology include: paralabral cysts; lack of labrum in
anatomical position; swollen labrum; displacement of labrum.
The presentation will also cover other aspects of shoulder ultrasound such as
assessment of subscapularis recesses; glenohumeral joint effusions and US guided
injections into the glenohumeral joint.
Characterizing Spinal Marrow Lesions using Diffusion
Weighted MRI
Dr Hirak Ray Choudhury.
Department of Radiology & Imaging
Advanced Medicare & Research Institute Hospital
Kolkata
Abstract:
The MRI appearance of the bone marrow in routine evaluation using T1- weighted, T2weighted, and STIR sequences.is determined by the relative amount of protein, water,
fat, and cells within the marrow. However the major determinants of signal
characteristics in various pulse sequences depends on the fat and water content.
Diffusion-weighted imaging (DWI) is based on the principle of mobility of water
protons in tissue. The apparent diffusion coefficient (ADC) is quantitative motion of
protons in tissues. The random, free motion of water protons in normal tissues results
in relatively high ADC values (high signal on an ADC map). Densely packed cells
within a tumor, or malignant infiltration restricts the motion of free water protons, thus
decreasing the ADC (low signal on an ADC map). Diffusion weighted MRI is used in
evaluation of vertebral collapse and infiltrating marrow lesions.
A 1.5T MRI scanner was used in a study conducted in our hospital. After routine MRI
sequences (T1, T2 , STIR and T1 with Gadolinium), all patients underwent DWMRI (SEEPI sequence) with b value of 400,800 and 1000, data taken in sagittal acquisition.
Qualitative analysis was done in DW images with b value 1000 since these images
show sufficient diffusion weighting and optimal contrast.
Quantitative evaluation of vertebral body signal intensity was measured using apparent
diffusion coefficient by placing a region of interest (ROI) cursor in the centre of each
abnormal vertebral body and measuring the signal intensity in each pixel within the
ROI. The qualitative (using variation in signal intensities) as well as quantitative (using
ADC measurement) data was used to determine possible benign or malignant etiology
of the marrow lesions. Statistical study and ROC curve showed a specificity of 83% and
a sensitivity of 85.7% DWMRI with ADC values of vertebral lesions provide useful data
to increase the radiological confidence in non-invasive diagnosis of vertebral marrow
infiltrating lesions thus restricting the recurrent use of invasive procedures for
diagnosis.
Suprascapular neuropathy
Dr. Joban Babhulkar DMRD, DNB
Consultant at STAR imaging and research centre,
Joshi Hospital Campus, Pune.
Abstract:
Suprascapular neuropathy is known cause of shoulder pain especially in the younger
population. Often missed, it requires a high level of clinical awareness. It is usually
caused by compression or traction of the nerve as its traverses the suprascapular or the
spinoglenoid notch. Compression or traction of the nerve can occur due to space
occupying lesions, traumatic injury or repetitive scapular movements. Asymptomatic
isolated infraspinatus atrophy is very common in volleyball players. The signs and
symptoms of suprascapular neuropathy can mimic those of a rotator cuff tear and often
present a diagnostic dilemma. EMG and NCV have been classically employed to
diagnose this neuropathy. We wish to establish the role of ultrasonography in the
evaluation of suprascapular neuropathy.
MRI of brachial plexopathies
Dr Jyoti Panwar Sureka, MBBS, MD, FRCR
Associate Professor at Department of Radiology,
Christian Medical College, Vellore, India
Abstract:
Magnetic resonance imaging (MRI) has become the primary imaging modality in the
evaluation of brachial plexus pathology, and plays an important role in the
identification, localization, and characterization of the cause. Improvements in MRI
technique have helped in detecting changes in the signal intensity of nerves, subtle
enhancement, and in detecting perineural pathology, thereby refining the differential
diagnosis. The brachial plexus abnormalities include trauma and a spectrum of nontraumatic causes, such as acute idiopathic/viral plexitis, radiation plexitis, metastases,
immune-mediated plexitis, and mass lesions compressing the brachial plexus.
MRI of impingement syndromes around ankle
Dr Kulvinder Singh MBBS, MD
Associate Professor & Head
BPS Govt Med College for Women,
Khanpur Kalan, Sonepat.
Abstract:
Ankle impingement syndromes are one of the most common cause of chronic ankle
pain, restricted movements and instability, particularly in athletes and active people.
Often, these conditions arise from chronic overuse, stress and microtrauma to the joint
and the resulting altered biomechanics further aggravates the pathology. Clinically and
anatomically, these syndromes have been classified as anterior, posterior, anteromedial,
anterolateral and posteromedial. Magnetic resonance imaging (MRI) by virtue of
excellent soft tissue resolution can demonstrate bony or soft tissue abnormalities in
these syndromes.
Imaging of Psoriatic Arthritis and Erosive Arthritis
Kunihiko Fukuda
Department of Radiology,
The Jikei University School of Medicine.
Abstract:
Psoriatic arthritis (PsA) is an inflammatory arthritis associated with psoriasis. The
radiological findings of PsA are characteristic. However, differential diagnosis between
PsA of the interphalangeal (IP) joints and erosive osteoarthritis (EOA) is sometimes
difficult.
●Radiological findings of PsA
In the peripheral joints, distribution of the disease is asymmetrical. Swelling of the
affected joints is present without juxta-articular osteoporosis. There are marginal bone
erosions in the bare areas, and fluffy bone formation adjacent to the joints and the shaft
of the bones. Involvement of more than two joints in the same digit can cause “sausage”
digit. Progressive central osteolysis results in joint destruction. Joint ankyloses can
occur in the phalangeal joints. New bone formation is also present in the entheseal sites,
such as Achilles tendon and plantar fascia attachment.
In the axial joint, the sacroiliac joints and the spine are involved. Bilateral sacroiliac
joints can be involved, but asymmetrical involvement is more common. Asymmetrical
non-marginal and/or syndesmophyte are present in the thoracic and lumber spine.
DISH-like bulky paraspinal ossification is sometimes accompanies with
syndesmophytes. Ankylosing spondylitis-like syndesmophytes with facet joints
ankylosis can occur in the cervical spine more frequently than in the thoracolumbar
spine.
●PsA and EOA: radiological findings of the fingers
Both arthrides involve IP joints of the digits associated with inflammation. EOA
involvement is limited to IP, 1st CMC, and triscaphe joints. Peri-articular inflammation
is less pronounce in the EOA, therefore, sausage-like dactylitis is not present in the
EOA.
Radiographically, both EOA and PsA have marginal erosions and they may progress to
central erosions. In typical case of EOA with central erosions, erosive patterns are
sometimes called as “gull wing” appearance or “saw-tooth” appearance. In some cases
with PsA, central erosion becomes wide spread osteolysis, which results in widening of
the joint space. Combinations of pointing-shaped osteolysis of the proximal head and
saucer-shaped osteolysis of the distal base appear “pencil-in-cap” type joint destruction.
Bone formations are characteristic features of PsA. It occurs in the capsular,
ligamentous, tendinous enthesis most of which are near the marginal erosions.
Periostitis along the shaft is also present. These new bones appear fluffy in the early
stage and become solid bones later. In case of EOA, bone formation is present as
osteophyte at the cartilage-bone junction similar to conventional OA. Both arthrides
eventually can produce bone ankylosis.
MRI of Ankle Ligaments
Dr.Kunwarpal Singh, M.B.B.S, DNB (RADIODIAGNOSIS)
Asst. Prof. in department of Radio-diagnosis and Imaging
Sri Guru Ram Das Institute of Medical Sciences & Research,
Amritsar.
Abstract:
The ankle joint is the articulation between talar dome and lower ends of tibia &
fibula. The plafond is the articulation between flat talar dome and flat surface of distal
tibia.The complex anatomy of ankle provides diagnostic as well as clinical challenge to the
radiologists and orthopedicians. Ankle injuries are the most common injuries sustained
during sports and even day to day activities. Magnetic resonance imaging has opened new
horizons in the diagnosis and treatment of many musculoskeletal diseases of the ankle. It
demonstrates abnormalities in the bones and soft tissues before they become evident on
other imaging modalities. The exquisite soft-tissue contrast resolution, noninvasive nature,
and multiplanar capabilities of MR imaging make it especially valuable for the detection
and assessment of a variety of soft-tissue disorders of the ligaments, tendons and other
soft-tissue structures.
Ultrasound of Tendon Lesions of the Ankle and Foot
Dr Lisa LS Wong
Hong Kong Imaging and Diagnostic Centre
Hong Kong.
Abstract:
The superficial locations of the tendons in the ankle and foot make these suitable for
assessment by high resolution ultrasound (HRUS). HRUS is readily available,
economical and portable and provides non-ionizing multiplanar imaging of these
tendons. It provides dynamic real-time assessment of these tendons and increases the
diagnostic accuracy of the examination. It can diagnose most tendon disorders
including tendinopathies, tears, dislocations, tenosynovitis and enthesopathies. These
different tendon pathologies will be discussed in the lecture.
HRUS provides real-time guidance for treatment of tendon pathologies. It allows
precise needle replacement in the desired location, avoiding unnecessary trauma to any
adjacent structures (e.g. neurovascular bundle) and increasing the efficacy of treatment.
HRUS is time consuming and is best utilized to answer a specific clinical question
related to a specific tendon rather than as a comprehensive examination of all tendons
in the ankle or foot. When pathologies involving multiple tendons and/or extratendinous structures of the ankle and foot are suspected (e.g. in the setting of acute or
severe trauma), MRI would be a more suitable imaging modality for more
comprehensive assessment.
Percutaneous management of Osteoid Osteoma
Dr M V Chalapathi Rao
Interventional Radiologist
Dr Chalapathi Rao’s IR Centre
Hyderabad.
Abstract:
Osteoid osteoma is an extremely painful benign bone tumor seen in young individuals.
Osteoid osteoma is usually smaller than 2 cm in diameter. It has a male predominance
and a male-to-female ratio of at least 2:1.
The typical symptom is local pain that is described as severe, sharp, boring, typically
worse at night. Pain is typically relieved with salicylates. The radiologic diagnosis is
accurate when combinations of bone scintigraphy, radiography, computed tomography
(CT), and magnetic resonance (MR) imaging are used. Together with clinical findings, a
confident, imaging-based diagnosis is possible. The major differential diagnoses are
Brodie’s abscess and occasional stress fractures.
Total removal of the nidus of the osteoid osteoma, however, is usually the treatment of
choice, and surgery has been considered the definitive treatment for many years.
Difficulty in lesion localization, the consequences of extensive dissection, the need for
prolonged recuperation, as well as the risk of incomplete removal and therefore
recurrence of the lesion, make surgery a less desired option in the management of
osteoid osteomas.
Percutaneous resection of the nidus with CT guidance allows precise localization of the
tumor with removal of less bone than at open surgery; hence, percutaneous resection
has less risk than does open surgery. The trephine needle used at percutaneous
resection, however, is often large, ranging from 7 to 10 mm in internal diameter. The
large size of the instrument may incur risk of neurologic and vascular injury in some
anatomic regions. Local complications such as hematoma, fracture or osteomyelitis are
recorded.
These disadvantages of percutaneous resection have encouraged the introduction of
less invasive therapeutic methods, such as CT-guided core drill excision,
radiofrequency ablation (RFA), alcohol injection, and interstitial laser ablation (ILA).
At RFA and ILA, the insertion of an electrode or fiber through a well-placed needle
allows direct delivery of energy from the machine to the tumor. Percutaneous RFA and
ILA have proved to be safe, quick, and minimally invasive methods of management.
Various studies have shown a high technical and clinical success rate, with minimal
immediate and delayed complications and morbidity. Percutaneous RFA and ILA
should be the methods of choice for treating percutaneously accessible osteoid
osteomas.
Imaging Of Talar Osteochondral Lesions
Dr Mahesh Prakash, MD
Additional Professor,
Department of Radiodiagnosis,
Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh,
India
Abstract :
Osteochondral lesions of the talus (OLT) are common cause of ankle pain and disability,
and they are often missed in the routine clinical evaluation of ankle injury. Imaging
plays important role for evaluation of these lesions. The goal of imaging in these lesions
is for their detection and demonstration of their position and extent. The assessment of
cartilage and surrounding cancellous bone are very important. Plain radiography (Xray), computerized tomography (CT), bone scan and magnetic resonance imaging (MRI)
are helpful in the detection and characterization of these lesions.
Plain radiographs are useful in the initial evaluation of patients however low grade
lesion can be missed. CT scanning can accurately identify and localize a lesion while
defining its extent but accurate assessment of overlying cartilage is a limiting factor. MR
imaging is best modality which can identify, localize, and define an osteochondral
lesion with the advantage of assessing the integrity of the overlying cartilage. The
present discussion will focus on the role of various imaging modalities with limitation
and their advantages .Imaging features of osteochondral lesions on each modality will
also be discussed.
Posterolateral Corner Of Knee
Dr Malini Lawande
Consultant in MRI dept
Dr Balabhai Nanavati hospital and
Consultant in Innovision Imaging
Abstract:
It is called ‘dark side ‘of knee as it is difficult to evaluate it clinically and also it is often
missed radiologically. It is an important structurally and functionally complex area.
Unrecognized and untreated posterolateral corner injuries lead to residual instability
and osteoarthritis as well as cruciate graft failure.
US guided tendon therapy: needling of the tendon
calcific deposit, needling of tendinopathy and injection
in the tendon sheets
Marina Obradov
Sint Maartenskliniek
Department of Radiology
Hengstdal 3, 6522 JV Nijmegen
The Netherlands
Abstract:
Extra-articular US guided musculo-skeletal interventional procedures are mainly
focused on the tendons primarily in the case of the tendon calcific deposit, the
tendinopathy and tenosynovitis.
MRI and US of Biceps Tendon Abnormalities
Mihra S. Taljanovic, MD, PhD, FACR
Professor (tenured) of Radiology and Orthopaedic Surgery,
The University of Arizona, Tucson, AZ.
Learning Objectives:
1. Learn MRI and US imaging techniques in evaluation of the biceps brachii
tendons and muscle
2. Learn normal anatomy and traumatic and pathologic conditions of the biceps
brachii tendons and muscle on high resolution MRI and US
The biceps brachii muscle is located in the anterior muscle compartment of the arm and
spans shoulder and elbow joints. This muscle has two heads (long-LH and short-SH)
and acts as supinator and flexor of the elbow and has role as dynamic stabilizer of the
shoulder, particularly with the arm in abduction and internal rotation. Injuries of both
proximal and distal biceps tendons can occur as a result of chronic stress/repetitive
trauma or acute traumatic injury with the proximal biceps being more commonly
affected.
The LH of biceps tendon (LHBT) originates from the superior glenoid labrum and
supraglenoid tubercle with known anatomic variants with respect to the labral
attachment and less common congenital duplication or accessory slip. The SHBT
originates from the tip of the coracoid process. Chronic repetitive microtrauma to the
LHB tendon, (frequently in association with overhead throwing sports) leads to
tendinosis and subsequent partial-thickness tear and eventual rupture. Tendinosis and
tears of the LHBT are commonly associated with tears of the supraspinatus and
subscapularis tendons, subluxation or dislocation from the bicipital groove, biceps
pulley lesions, and various types of SLAP tears of the superior labrum. Acute ruptures
of a healthy proximal LHB tendon are rare. Excess synovial fluid complex in the LHBT
sheath, in the absence of a significant glenohumeral joint effusion is indicative of
tenosynovitis. Diagnosis of the proximal LHBT lesions is best achieved with high
strength MRI or MR arthrography. US examination provides excellent evaluation of the
LBHT in the bicipital groove and most of time in the region of the rotator cuff interval.
However, US evaluation of the biceps anchor and bicipitolabral complex is frequently
suboptimal. Isolated ruptures of the proximal LHB tendon do not require operative
treatment but tenodesis or tenotomy may be performed in symptomatic tendon
ruptures or for severe tendinosis or partial-thickness tears. Tears of the biceps brachii
muscle belly are rare and may be diagnosed equally well with MRI or US imaging.
The distal BT is an extra-synovial structure without tendon sheath which is formed by
contribution of the SH and LH of the biceps muscle approximately 7 cm above the
elbow joint with attachment onto the radial tuberosity. These two tendons may have
isolated attachments. The superficial fibres form a broad aponeurosis, lacertus fibrosus
(LF) which sweeps across the antecubital fossa covering the superficial forearm flexors
and protecting the median nerve and brachial artery. The bicipitoradial and
interosseous bursae are located about the distal BT attachment site and may be
distended (inflamed), frequently in association with tendinopathy and/or partialthickness BT tear. Distal BT injuries are usually result of acute trauma. If the BT is
avulsed from the radial tuberosity and the LF is torn, the torn tendon retracts into the
upper arm. With intact lacertus fibrosus, there is only minimal BT retraction, making
the diagnosis more difficult. DBT tears frequently result in functional disability and
surgical repair within 2 weeks is desirable. Distal BT retraction of less than 8 cm
typically correlates with an intact LF, while larger retraction indicates LF tear. With the
bifid DB, isolated rupture of a single tendon may occur. Retraction of the LHBT causes a
deformity with a “Popeye sign,” mimicking a complete tear. Muscle retraction may not
be present with isolated tears of the SH with intact LF. Traumatic and pathologic
conditions of the distal BT can be diagnosed equally well with MRI or US.
Avulsion Injuries
Dr. Pramod Kolwadkar MBBS Ngp, MD Rad, AIIMS Delhi, DMRE Mumbai, FICRI
Consultant Radiologist
Abstract:
Avulsion injuries can occur, either due to day to-day trauma, or during athletic and
sporting activities. Whenever forcible pull of a strong ligamentous or tendinous
attachment, pulls a fragment of bone, away from the rest of the bone - it is called
avulsion fracfure,Commonest forces, producing awlsion fractures are-tension,
stretching, torsion and shearing forces. Avulsion fractures, as well as sports injuries, are
cofirmon in children & adolescent age, due to their relationship with growth. Thus most
of the avulsion injuries are related to the growth spurt. Growth iissue is i,he weakest
link in the bone. Hence avulsion fractures are common in children and adolescents.
Avulsion fractures are commonest in apophyseal regiono physeal aren and articular
epiplyseal region, in order of occurance. In this , talk, various examples of avulsion,
fractures in apophyseal region e:g. Osgood- Schlatter lesion, are discussed.
Similarly physea[and epiphyseal avulsion injuries have been demonstrated. Discussion
also denotes, the various muscles involved, age - groups and the responsible sports or
athletic activities.
Epidemiological aspect is also dealt with.
Approach To Pediatric Metabolic Bone Disease
Dr. Rakhee Kumar Paruchuri MBBS, DNB, FRCR
Assistant Professor,
Nizam’s Institute of Medical Sciences,
Hyderabad.
Abstract:
Metabolic bone diseases encompass a large spectrum of disorders that can result from
genetic, endocrine, nutritional and biochemical disorders. Some of these conditions are
reversible once the underlying defect has been identified and treated; some stabilize
once the bones stop growing, while others require lifetime management.
Metabolic bone diseases are commonly caused by abnormalities of minerals such as
calcium, phosphorus, magnesium or vitamin D that affect bone as a tissue. These
manifest as either of the two presentations, i.e, osteopenia or osteosclerosis. The
radiographic changes may be diffuse or multifocal, although occasionally focal lesions
may be seen. Some pathologies have characteristic appearances, such as rickets, scurvy
and hyperparathyroidism, while some shownon specific features. Certain pathologies
are seen only in neonates. Thus, a high index of suspicion is required with clinical and
lab correlation to reach the correct diagnosis.
MRI of tendons in the wrist
DR. SANJAY DESAI MBBS, MD, DNB (RADIODIAGNOSIS)
Fellow ISVIR, Erasmus Musculoskeletal Fellow (Europe).
Consultant radiologist in Star Imaging centre, Pune.
Abstract:
Magnetic resonance imaging represents a relevant way to diagnostically assess the wrist
with high-resolution, multiplanar imaging without employing ionizing radiation. It
influences clinical and surgical diagnosis and management of wrist pathologies.
The flexor and extensor tendons present typical low signal intensity and constant
diameter on all sequences.
Tendinopathy presents as signal and thickness changes on MRI, and may progress to
partial- or full-thickness tears, with or without associated fluid and synovitis of the
sheath (tenosynovitis). Tenosynovitis could be due to multiple causes besides
overuse/degenerative changes (as in De Quervain’s tenosynovitis).
An intersection syndrome refers to pain and swelling at areas of intersection between
the tendon compartments – can be proximal (crossing between the 1st & 2nd extensor
compartments at the distal dorsal radial aspect of the forearm) or distal (crossing
between the 3rd and 2nd compartments at the level of tubercle of Lister).
In cases of direct trauma to the tendon, it can be torn with / without retraction; in the
latter the tendinous stumps need to be identified and the protocol tailored to the clinical
question as required.
In case of tendon injury at its bony attachments, the protocol needs to be altered and
tendons followed upto their finger insertions for accurate identification of site (zone) of
injury esp. in flexor tendons.
Uncommonly, there can be a congenital absence / duplication of tendons which can be
identified only if there is a high index of suspicion.
Imaging of sesamoids and accessory ossicles of the foot
Major General (Dr.) Sanjeewa Munasinghe RWP. RSP. USP. MBBS. MD.
Consultant Radiologist,
Army Hospital, Colombo, Sri Lanka.
Abstract:
Sesamoids are osseous structures, often small, found partially or totally
embedded in a tendon or joint capsule, typically in locations where a tendon passes
over a joint. The accessory ossicles are supernumerary bones that commonly derive
from unfused primary or secondary ossification centres and are considered to be
normal variants. There is wide variation in the prevalence and appearance of sesamoids
and accessory ossicles in the foot.
Though the clinical significance of presence of these osseous structures is
probably minor, these bones may be associated with painful conditions due to various
pathologies, including trauma, infection, inflammation, degeneration, arthritic and
neoplasm. Therefore, knowledge of their presence and morphological variations is
important to ovoid misinterpretation.
Sesamoids and accessory ossicles share several imaging characteristics: They are
usually small, well-corticated, ovoid or nodular, may be bipartite or multipartite, are
found close to a bone or a joint. It may be difficult to distinguish between incidental
variants and truly symptomatic bones. Although the recognition of pathological
conditions in these small osseous structures are often challenging, imaging modalities
including plain radiography, ultrasound, scintigraphy, computed tomography (CT) and
magnetic resonance imaging (MRI) provide valuable diagnostic information.
Plain radiographs confirm the presence of sesamoid or an ossified accessory bone
and may suggest fractures of these. Cartilaginous or non-ossified accessory bones may
be identified on ultrasound, which can also be useful in the evaluation of adjacent soft
tissue for signs of inflammation and injury. Scintigraphy has the highest sensitivity in
the localisation of the cause of foot pain to a sesamoid or an accessory ossicle but is non
specific. CT readily demonstrates fracture and degenerative changes at a synchondrosis
or articulation, and can also evaluate for increased sclerosis as seen in osteonecrosis.
However, MRI is most useful in the evaluation of pathology associated with sesamoids
and accessory ossicles. MRI findings are relatively specific for infection, osteoarthritis
and fractures, and provides superior evaluation of adjacent soft tissues.
Profile of wrestling injuries
Dr. Shalini Agarwal (M.D, DNB, MNAMS, PGDHHM, Commonwealth Fellow)
Professor, Department of Radiodiagnosis,
Pandit Bhagwat Dayal Sharma, PGIMS
Rohtak.
Abstract:
Wrestling is a popular sport in many countries around the world. Its origin can be
traced back to the Sumerians as early as 5000 BC, and records of ancient Olympic
wrestling date back to the Greeks in 708 B.C. In India its popularity is increasing
everyday with wrestlers like Sushil Kumar, Yogeshwar Dutt and Amit Kumar Dahiya
winning medals in Olympic & World Championships. The two styles of wrestling
recognized internationally are Greecoroman, which made its debut in the first modern
Olympics in Athens (1896), and Freestyle, included in the Olympic program in Saint
Louis (1904). It is a contact sport with extreme physical demands and its practice is
associated with an elevated incidence of orthopedic injuries.
According to data from the centre for injury and policy, football and wrestling are the
two sports with the high risk of serious injury to athletes. Reported match injury rates
are as high as 30.7 injuries per 1000 athlete-exposures among college wrestlers second
only to injury rates among college football players. In a study conducted by Myers et al
(2010) it was found that the annual cumulative injury incidence was 6.49 injuries/1,000
wrestlers/year for the youth group and 29.57 injuries/1000 wrestlers/year in the
scholastic group, this likely reflects the level of injury that present to the emergency
department.
Knee and shoulder the most frequently injured body parts and takedowns and sparring
the most common activities at the time of injury. Increased duration of practice is
associated with higher injury rate. Recurrent injuries especially ligament sprains and
muscle strains are most common in wrestlers. Pasque et al (2000) reported that 6% of
the athletes injured in the preseason suffered a re-aggravation of that injury during the
regular season. The injury incidence rates have been found to be higher during
tournaments than during practice. However, more number of injuries occur during
practice as significantly more time is spent in practice sessions. There is wide variability
in reporting these injuries, hence more studies need to be conducted. These studies help
towards development of preventive programmes and hence are essential component of
training of wrestlers. The speaker conducted a prospective study over 02 years
involving 196 wrestlers and will be sharing her experience with the audience.
HRUS: Approach In Arthritis
Dr. Shamrendra Narayan
MBBS, MD (Radiodiagnosis)
Assistant Professor in Radiodiagnosis
Sarojini Naidu Medical College, Agra
Abstract:
Diagnosis and classification of arthritis on part of the treating clinician is a challenge
due to lack of specific clinical diagnostic criteria. The confusion is further added by
many nonspecific and overlapping serology. X-rays have been the mainstay of the
radiological assessment of joint disorders. However conventional radiography is not
capable of assessing soft tissue as well as early bone abnormalities. Though the gold
standard for the assessment of soft tissue abnormalities is MRI, in the last few years,
musculoskeletal HRUS has made its presence felt among rheumatologist and
radiologist. Ultrasound is an attractive imaging modality for evaluation of arthritis due
to excellent resolution, lack of ionising radiation, non-invasiveness, portability and low
cost. Dynamic and real-time assessment and Doppler imaging are additional benefits of
this modality. MRI does score in evaluating the intra-articular derangements and
marrow edema but that is hardly a consideration for evaluation of arthritis as tool for
routine imaging. Axial skeleton is another area where HRUS has failed to mark its
utility. Moreover the resolution of HRUS scores over MRI especially with freedom to
compare contralateral and other involved joints in the same interaction.
Extrapolating the clinico-pathological criteria into an imaging spectrum by HRUS is
rewarding not only for making a diagnosis but also for follow up.
Imaging Of Tuberculous Spondylodiscitis
Sri Andreani Utomo
Department of Radiology, Dr. Soetomo Hospital
Faculty of Medicine, Airlangga University, Surabaya, Indonesia.
Abstract:
Tuberculosis (TB) remains endemic in most of the developing countries. TB not
only in the lungs, but also in extrapulmonary sites, e.g. spine. Spinal TB is most often
found in the lower thoracic and upper lumbar regions. Diagnosis is often difficult;
clinical findings are usually non-specific and radiologic features may mimic those of
other bacterial, fungal, inflammatory and neoplastic diseases.
However, recognition and understanding of the radiological findings may help
in diagnosis. The classic pattern of TB spondylodiscitis, characterized by destruction of
two or more contiguous vertebral bodies and opposed end plates, disk infection, and
commonly a paraspinal abscess and granulation.
Rarely, TB spondylodiscitis may affect only a single vertebral body with or
without disk involvement and this may lead to diagnostic confusion, metastatic disease
and mycobacterial infection become more prominent in the differential diagnosis. Thus,
awareness of the variability of imaging findings in spondylodiscitis is important in
minimizing delays in diagnosis.
Both malignant tumor and infection involve the bone marrow, revealed
decreased signal intensity on T1-weighted images and increased signal intensity on T2weighted images.
Malignant spinal tumor was differentiated from spondylitis by lack of disc
involvement with tumor cells. The disc outline in spondylitis was usually irregular and
disc intensity was increased on T2-weighted images.
The suggested clue that can help differentiate between malignant spinal lesion
and spinal infection are associated findings such as the endplate and disc involvements
that mostly found in spinal infection.
Plain radiography of tuberculous spondylodiscitis may demonstrate loss of
vertebral height, disk space narrowing, erosions, indistinction of the end plates,
paravertebral mass- es, and soft tissue calcifications. However, plain radiography is
insensitive for the early detection of vertebral TB.
CT is of great importance in demonstrating small, early foci of bone infection and
the extension of the bone and soft tissue involvement. CT may also be used in the
follow-up of patients under treatment with antituberculous chemotherapy. End plate
destruction, fragmentation of the vertebrae, and paravertebral calcifications are
adequately demonstrated. After administration of intravenous iodinated contrast
paravertebral and/or epidural abscesses may show thick, nodular wall-enhance- ment
and a sinus tract may ade- quately be delineated.
Multiplanar capability and superior soft tissue contrast make MR imaging the
modality of choice in the evaluation and follow-up of spondylodiscitis. A major
advantage of MR imaging, compared with CT scan and plain radiography, is the higher
sensitivity for detection of early inflammatory bone marrow changes and infiltrative
end plate changes in the vertebra. MR imaging is mostly useful in delineating
paravertebral, epidural, and intraosseous abscesses and in evaluation the extent of cord
compression and the presence of intramedullary lesions.
A positive culture or histopathologic analysis with CT-guided needle aspiration
or biopsy specimens is required in the absence of pulmonary manifestations of
tuberculosis and in diagnostic confusion, it is important for definitive diagnosis and
adequate treatment.
Imaging Of Primary Tumors Of Spine
Dr. Sujata Patnaik
Additional Professor
Department of Radiology and Imageology
Nizam’s Institute of Medical Sciences, Hyderabad.
Abstract:
Primary spinal tumours are rare and distinctive because of the diagnostic challenges.
Early and appropriate institution of treatment results in better prognosis. Age at
presentation, location of the tumour and pattern of the lesion are all important
parameters for reaching a diagnosis. Among malignant spinal tumours metastatic
disease, myeloma and lymphoma are the most common at diagnosis- metastatic
tumours constituting 40-80%, followed by multiple myeloma and Plasmacytoma. Nonlymphoproliferative lesions accounts for only 2.5-8.5%. The spectrum of spinal tumours
include bone forming tumours ( enostosis , osteoid osteoma , osteoblastoma and
osteosarcoma), cartilage forming tumours ( Osteochondroma , Chondroblastoma and
chondro-sarcoma), lymphoproliferative tumours ( multiple myeloma ,Plasmacytoma,
lymphoma, leukaemia),tumours of notochordal origin (Chordoma), tumours of fibrous
origin (benign and malignant fibrous histiocytoma and fibrous dysplasia), round cell
tumour (Ewing’s sarcoma), primitive neuro ectodermal tumours (PNET) ,vascular
tumours(hemangioma, epithelioid hemangioendothelioma , hemangiopericytoma) and
others ( aneurysmal bone cyst (ABC), giant cell tumour (GCT). Rare tumours like
leiomyoma, leiomyosarcoma, neurogenic tumour can occur in osseous spine.
Conventional radiography is the initial diagnostic tool and also helps for decision
regarding stabilisation of spine. CT and MRI are important for further evaluation,
defining the extent (as spine is anatomically complex) and for staging of tumours. CT
better evaluates vertebral body collapse and bone destruction; while MRI is preferred to
assess epidural component and neural structure involvement. Newer advances like
Dynamic contrast enhanced MR perfusion imaging, Proton spectroscopy and Diffusion
imaging helpful in narrowing the differential diagnosis, differentiating responders from
non-responders and residual lesions from recurrent lesions due to radiation necrosis.
Radionuclide studies are sensitive to any area of increased osteoid reaction to
destructive bone process to both lesions as small as 2 mm and as little as 5-15% of
alteration in local bone turn over. PET/CT is useful for assessment of extent, staging,
and follow-up of various spinal lesions. Angiography depicts vascularity and is used
for selective embolization of hyper vascular tumours. Biopsy is required in most cases
to establish final diagnosis.
Osteiod osteoma and osteoblastoma occur in posterior elements and in younger age group.
Nidus is characteristic and appears as lucency. When more than 1.5cm it is called
osteoblastoma and smaller one is termed as osteoid osteoma. At times nidus may be
obscured by sclerosis. Osteoblastoma may have aneurysmal cyst component with fluidfluid level. Four percent of all osteosarcomas occur in spine; commonly arise from
posterior elements. Dorsal and lumbar regions are more commonly involved than
sacrum or the cervical spine. Matrix mineralisation and lesions with varying amount of
osteiod production, cartilage /fibrous tissue are frequently seen. Rarely tumour with
marked mineralisation may produce ivory vertebra. Osteochondroma is a pedunculated
cauliflower lesion with marrow or cortical continuity with parent vertebra. Spinous
process is more common site than transverse process; which is more common than
lesions in vertebral body. Chondroblastoma has predilection for growing skeleton. About
1.5 % of chondroblastomas occur in spine involving vertebral body and posterior
elements. Spinal chondrosarcoma accounts for 4% of all chondrosarcoma. They frequently
present in 3rd to 7th decade. Thoracic and lumbar vertebrae are more commonly
involved than sacrum presenting as large calcified mass with bone destruction.
Chondroid matrix mineralisation is better demonstrated on CT. Non-mineralised
portion is highly bright in T2w images. Ring or arc like enhancement is characteristic.
Multiple myeloma presents with punched out lesions and Plasmacytoma with collapse of
vertebral body or expansile lesion having soap bubble appearance. These are common
in elderly patients. Spinal lymphoma accounts for 1-3% of all lymphomas. Lesions may be
lytic, sclerotic or mixed. Focus of bone marrow replacement and surrounding soft tissue
mass without large areas of cortical destruction suggest lymphoma. Ewing’s Sarcoma and
PNET occur in children mostly in 2nd decade. These lesions are seen in the posterior
elements. Chordoma is most common primary spinal tumour occurring in 5th to 6th
decade. Sacro-coccygeal (50%) and spheno-occipital region (35%) and vertebral body
(15%) are the common locations. These present as expansile lytic lesions with soft tissue
with areas of calcification. Hemangioma is the most common benign vertebral lesion
having characteristic corduroy / honey-combing appearance and is often incidental
finding. Hemangiopericytoma of spine is rare. ABC occurs in posterior arch and GCT in
vertebral body.
MR Imaging of Rotator Cuff Injury
Dr Sunitha Linga Reddy
Director – Lucid Medical Diagnostics
Abstract:
The supraspinatus,infraspinatus,teres minor and subscapularis muscles constitute the
rotator cuff. The supraspinatus,infraspinatus,and teres minor tendons insert on the
greater tuberosity whereas the subscapularis tendon inserts on the lesser tuberosity. The
rotator cuff is a functional-anatomic unit rather than four unrelated tendons, and injury
to one component may have an influence on other regions of the rotator cuff.
Infection of the Skull bones, a less known entity
Dr. Virinder Mohan
Professor Emeritus, Radiodiagnosis,
R M C H, Bareilly, U P INDIA
Prof.Virinder Mohan and Dr.Nimisha Batra
Postgraduate Deptt.of Radiodiagnosis and Imaging,
Subharti Medical College, Swami Vivekanand Subharti University, Meerut INDIA.
Abstract:
Infections of bones is one of the common entity encountered by the Radiologists and the
Orthopaedic Surgeons in their day to day practice more so in this part of the world.
While long bones are the favourite site for pyogenic infection, vertebral column and the
joints favour Tuberculous infection.
Skull bones involvement in any form of infection is much less common and hence the
correct diagnosis skull bones osteomyelitis remains a diagnostic challenge, more so
since the imaging findings in skull bone infections may mimic many conditions in
different age groups including primary benign and malignant tumours and the more
common metastatic malignancy. However, a good clinical history and a good clinical
examination and a high index of suspicion in a given case together with critical analysis
of various imaging finding may clinch the diagnosis in majority of cases even before
histopathology.
Imaging of posterior tibial tendon dysfunction
Dr. Adnaan Sheikh
Associate professor of radiology
University of Ottawa, Canada.
Abstract :
Posterior tibial tendon dysfunction is one of the most common problems of the foot and
ankle. It occurs when the posterior tibial tendon becomes inflamed or torn. As a result,
the tendon may not be able to provide stability and support for the arch of the foot,
resulting in a flatfoot deformity.
This talk will help you to understand the anatomical, biomechanical and imaging
features of the posterior tibialis tendon dysfunction.
Role of MRI in the post-operative shoulder
Dr. Ankur Janakray Shah.
Consultant radiologist and head
Sadbhav Imaging Centre, a division of Gujarat Imaging Centre,
Ahmedabad
Abstract:
Interpretation of MR Images of the post-operative shoulder can be a difficult task for the
radiologist. There are numerous surgical procedures, all with particular approaches and
complications. Surgical artifacts often make the study even harder to evaluate. Still,
MRI can provide a great deal of information to the referring clinician regarding patients
with recurrent or new symptoms after surgery.
Most shoulder surgeries fall into one of two categories: 1) rotator cuff / impingement
surgery and 2) labral / capsular surgery in patients with instability or pain from labral
tear. It is very helpful to know the surgical history when deciding the study protocol
and reviewing the MRI images.
Gradient Echo images are more prone to metallic susceptibility artifacts from metallic
and should be avoided. Fast spin echo sequences results in less artifacts compared to
spin echo sequences and hence are more handy tool. MR arthrography plays a very
important role in imaging of post-operative shoulder imaging.
MRI findings have to be evaluated as per the procedure performed. As after every
procedure, certain MR findings are related to the procedure and not considered as any
pathology. At the same time it is very important to know the complications or abnormal
findings that are likely to occur after a specific procedure to look specifically for them
on MR images. It is important to remember that pathological findings in non-surgical
patients may be “Normal” in post-operative situation.
MRI Knee: Cruciate And Collateral Ligament
Dr. Hemant Patel, DNB,MD,DMRE
Professor at Gujarat Imaging Centre,
postgraduate institute of Radiology, Ahmedabad, India
Abstract:
Injuries of the knee are common. Trauma and sports-related activities are the most
frequent causes of knee injuries. Secondary to their role in maintaining stability, the
ligaments of the knee are commonly involved in these injuries. To prevent long-term
sequelae, early diagnosis and treatment, whether conservative or surgical— are key in
planning management of these injuries. Because of its excellent oft-tissue contrast,
magnetic resonance imaging (MRI) has proven very useful for identifying these
important structures. The immediate post-injury period, clinical assessment of the knee
is unreliable, which accentuates the importance of MRI as a diagnostic tool.
Lumbar disc : Protrusion, Extrusion and Confusion
Dr. Jinna Jagan Mohan Reddy
Radiologist , Clinical Imaging Dept., MRI Section,
Mafraq Hospital, Abu Dhabi, U.A.E.
Abstract:
Low back pain ( LBP) is defined as pain between the lower ribs and gluteal folds, with
minimal radiation to the thigh and never below the knee.
LBP with sciatica is defined when there is back pain together with radiating pain in the
leg below the knee.
Lumbar disc is common cause of low back pain. Lumbar disc can be classified in one of
the
following
categories:
Normal,
Congenital/developmental
variation,
Degenerative/Traumatic, Infection/Inflammatory, Neoplastic and or Morphologic
variant of uncertain significance. The data is categorized as possible , probable and
definite.
Congenital and developmental variations are congenitally abnormal eg. scoliosis or
spondylolisthesis
Degenerative/Traumatic : These include annular tears, herniation and degeneration.
Trauma is not a major factor. Annular tears are fissures in annular fibres
Degeneration may include desiccation, fibrosis, narrowing of disc space, diffuse bulging
disc beyond annulus, defects and sclerosis of the end plate and osteophytes. Herniation
is defined as a localized displacement of the disc material beyond the limits of
intervertebral disc space (DEBIT). The disc material may be nucleus, cartilage,
fragmented apophyseal bone, annular tissue. The disc can be focal (<25%), broad based
(25-50%), and bulge (diffuse) .
Herniated disc may be protrusion or extrusion. Protrusion, if the greatest distance in
any plane between the edges of the disc material beyond the disc space is less than the
distance between the edges of the bases (posterior margin of the disc)
Extrusion , the disc material is greater than the distance between the edges of the base.
Sequestration, displaced disc has lost continuity with parent disc. Migration is
displacement of the disc from site of extrusion
Inflammation/infection include infection and inflammation of the disc
Neoplasia can be primary or metastasis
Morphological variant of unknown significance suggest abnormal morphology of the
disc
In relation to posterior longitudinal ligament the disc material can be sub ligamentous,
extra ligamentous, trans ligamentous or perforated. Volume of canal compromise of less
than one third of the canal is mild, between one third and two thirds is moderate and
over two thirds is severe. Composition of the displaced material may be characterized
as nucleus, cartilaginous, bony, calcified, ossified collagenous, scarred, desiccated,
gaseous or liquefied.
Location: Anatomic zones and levels are defined using following land marks. Medial
edge of the articular facets, medial, lateral upper and lower borders of the pedicles and
coronal and sagittal planes at the center of the disc.
On the axial plane these land marks determine the boundaries .Central zone,
subarticular zone, foraminal zone and extra foraminal zone. In the axial plane moving
from centre to right lateral is defined as central, right central, right subarticular, right
foraminal or right extra foraminal.
On the sagittal plane they determine the boundaries of the disc level, infrapedicular
level, pedicular level and suprapedicular level.
In the coronal plane anterior in relation to the disc means ventral to the mid coronal
plane of the vertebral body.
American Society of Spine Radiology and other societies have formed a task force to
standardize different terminology used in lumbar disc as there is contradictory views
and confusion about the terms used in routine practice. I will discuss the
recommendations of the task force in the talk.
Facet Joint Arthritis
Dr. Lalitha Palle MBBS, MD, DNB, FICR.
Associate Professor & Consultant Radiologist.
MBA in Hospital Administration. Yashoda Hospitals.
Hyderabad.
Abstract:
Arthritis of the lumbar facet joints can be a source of significant low back pain. Aligned
on the back of the spinal column, the facet joints link each vertebra together. They are
synovial joints and articular cartilage covers the surfaces where these joints meet. The
common changes affecting the facet joints is degenerative disease. Inflammatory, septic
and tubercular arthritis is relatively uncommon. Radiographs, CT and MRI can help
pick up the disease and grade it.
Imaging of patellar instability
Dr Anupama Patil
Director and Chief radiologist musculoskeletal imaging
STAR diagnostic and research centre, Pune.
Abstract:
Patellar instability is a part of the patello-femoral pain/instability syndromes. The
presence of patellar instability is essentially a clinical diagnosis , however radiology
plays an important role in the assessment of a patient so that the orthopaedic surgeon
may then plan his treatment protocol . It is extremely important that we know exactly
what parameters are required by the surgeon and should be mentioned in our reports.
The imaging modalities include plain radiographs, CT and MRI Scanning.
Radiographs and CT help in the assessment of the Q angle which is an important
determinant in the treatment protocol. The skyline view is another important x-ray
yielding information which perhaps cant be gleaned on CT or MRI.
The mainstay of imaging however is MRI, preferably with a high field strength so that
the cartilage may also be adequately assessed.
Various parameters such as patellar height, patellar tilt, presence or absence of trochlear
dysplasia, integrity of the medial stabilisers of the knee and status of patella-femoral
cartilage are assessed.
This lecture aims to cover all of the above radiological parameters as well as some
points on what the clinician/orthopaedic surgeon expects to be covered in our report.
Imaging of the Lumbosacral plexus and its technical
considerations
Chhabra Avneesh
Chief Musculoskeketal Radiology, Associate
Professor
Radiology
and
Orthopedic
Surgery, UT Southwestern Medical Center,
Dallas, Tx
Abstract:
The lumbosacral (LS) plexus is a network of nerves formed by the ventral rami of the L2
through S3 nerve roots. Its anatomy is complex, and its various branch nerves show a
number of variations traveling obliquely in their retroperitoneal course and relatively
straight in the lower limbs. Three-dimensional (3-D) imaging with multiplanar
reconstruction is essential for evaluating neuromuscular anatomy in the abdomen and
pelvis. This talk will focus on 3-D imaging of the LS plexus and its technical
considerations, and the reader will gain knowledge of the 3-D anatomy and various
pathologies of the LS plexus branch nerves.
Cervical Disc Nucleoplasty
Dr Ian Y Y Tsou
Department of Radiology
Mount Elizabeth Hospital, Singapore.
Abstract:
Intervertebral disc nucleoplasty or discoplasty is a method of disc material ablation.
Unlike previous methods such as radiofrequency (RF) or intradiscal elecctrothermal
annuloplasty (IDET), it does not cause such high temperatures during the procedure, as
coblation rather than heat is used.
Ablation of the intervertebral disc is aimed at causing vapourisation of the disc
material, with resulting loss of volume and fibrosis, leading to retraction of the
abnormal bulging or herniated portion of the disc.
Although the manufacturer of the nucleoplasty product suggests using fluoroscopy as
the method of imaging guidance, the radiologists at our centre (Mount Elizabeth
Hospital, Singapore) realised that CT-fluoroscopy is a much safer option, in terms of
reducing risk of vascular or nerve injuries, and also to be able to shorten the procedure
time.
The lecture will focus of the technique of the cervical nucleoplasty procedure utilising
CT-fluoroscopic guidance, appropriate selection of patients for the procedure and
potential complications and tips and tricks for safe performance of the procedure.
Imaging of extradural lesions of the spine
Jianling Cui, Jinjun Ren, Jiaojiao Fan, Yun Zhang
Department of Radiology,
The Third Hospital of Hebei Medical University,
Shijiazhuang, Hebei 050051, China
Abstract:
The extradural lesions in the spine are not commonly seen. In this article we discuss the
MRI features of pure extradural lesions of spine and their differential diagnosis.
The nontraumatic spinal epidural hematomas (NSEH) are the most common lesions in the
spinal epidural space, following by hemangioma, abscess, angiolipoma, metastasis,
arachnoid cyst, meningioma. The hydatid cyst, multiple myeloma, lipomatosis, leukemia,
lymphoma, hematopoiesis, ependymoma, hemagioblastoma, myelolipoma are rare.
The MRI features of NSEHs are similar to intracerebral hemotoma, which are low signal
or mixed signal in T2WI，some high signal areas in the T1WI, only the capsule is enhanced
after Gd-DTPA injection intraveneously. The features of cavernous hemangioma are
isointensity comparing to spinal cord on T1WI, very high signal on T2WI, obvious
enhancement homogenously after Gd-DTPA injection. The low signal on T1WI and high
signal on T2WI in a plain MR scan with irregular thick wall enhancement after contrast agent
injection are the features of epidural abscess. Fat and blood vessel component exiting in one
mass are the features of angiolipomas. A lot of epidural masses, such as neurilemoma,
metastasis, meningioma, and multiple myeloma and so on, show isointensities comparing to
spinal cord on T1WI and T2WI. Large cyst with CSF like signal inside are the features of
epidural arachnoid cyst and hydatid cyst, former is relatively common.Conclusion: The pure
epidural masses are clearly shown by MR imaging and making a diagnosis are not very
difficult for the most cases
High Resolution Ultrasound In Knee Joint Swellings
Jyotsna Sen MBBS MD
Professor, Pt B D Sharma PGIMS
Rohtak, Haryana
Abstract:
Knee joint is one of the important weight bearing joints and is affected by a variety of
disorders which can be congenital, traumatic, degenerative, metabolic or systemic
(rheumatoid/psoriatic arthritis). High resolution sonography is emerging as a time
efficient, non invasive, economical imaging tool for assessment of knee lesions because
of its ability to visualize fibrillar microanatomy of tendons, ligaments, menisci and soft
tissues. The knee joint is divided into four compartments- anterior, posterior, medial
and lateral for anatomic localization and diagnosis of its pathology. The sonographic
features of the various causes will be discussed.
MRI and US of Biceps Tendon Abnormalities
Kyung Jin Suh
Professor
Department of radiology
Chief of Musculoskeletal Section
Head of Diagnostic radiology, Nuclear medicine
Dongguk University Gyeongju Hospital,
College of Medicine, Dongguk University, Korea.
and
Radiation
oncology
Abstract :
Objectives:
•
•
•
The pathologic changes of intraarticular LBT (long head of biceps tendon) cause
shoulder pain and disability and also commonly related to rotator cuff
pathology.
Although the diagnosis of LBT abnormality on arthroscopy or even open surgery
could be difficult, shoulder MR arthrogram may be a better modality providing a
definite diagnosis.
For the definite imaging diagnosis of various pathologic lesions of intraarticular
LBT we introduce the illustrative cases of biceps tendon abnormality on shoulder
MR arthrogram.
Conclusion:
• Arthroscopic Diagnosis of LHBT abnormality and instability is difficult
• Neglected LHBT pathology – postoperative shoulder pain
•
•
MR arthrographic findings of abnormal LBT are tendinopathy or localized
hypertrophic change, instability and rupture of intraarticular long head of biceps
tendon.
Though biceps tendon abnormalities with rotator cuff disease or biceps pulley
lesion are common association, arthroscopic surgical view is sometimes
inappropriate to confirm the LBT abnormalities, especially in case of
tendinopathy or localized hypertrophic change. MR arthrogram could be used as
a most useful and reliable diagnostic modality for evaluating the LBT
abnormalities.
MRI of Rotator Interval
Madhusudana Rao Tummala, M.D.
Hurley Medical Center
Department of Radiology
One Hurley Plaza, Flint
Michigan
Abstract :
Rotator interval is a triangular space on the anterior superior aspect of the shoulder. It is
located at the level of the coracoid process between the anterior edge of the
supraspinatus tendon and superior margin of the subscapularis tendon. The cartilage
covering the humeral head serves as its floor. Rotator interval capsule is the anterior
superior aspect of the gleno humeral joint capsule.
Rotator interval capsule is reinforced externally by the coracohumeral ligament and
internally by the superior glenohumeral ligament. The tendon of the long head of the
biceps lies in the rotator interval extending from its origin at the supraglenoid tubercle
towards bicipital groove. Biceps pulley stabilizes and maintains the biceps tendon in the
bicipital groove.
The complex anatomy and lesions of the rotator interval components, including the
contents of the rotator interval, are important for the stability and proper functioning of
the shoulder.
The biceps instability, capsular and ligamentous abnormalities, adhesive capsulitis and
lax shoulder will be presented.
Ultrasound of the Elbow
Dr Niraj Dubey, FRCR.
Senior Consultant Radiology and Musculoskeletal Imaging
Dept of Diagnostic Radiology
Khoo Teck Puat Hospital, Singapore.
Abstract:
Ultrasound examination of the elbow is an expedient and economical method of
evaluation of the various pathologies around the elbow joint. It’s easy availability and
ease of examination make it an extremely useful tool which in conjunction with a
relevant history and clinical evaluation is able to answer most of the questions related
to the elbow. Additionally, intervention in the elbow, both diagnostic and therapeutic is
a very large part of the workload of the MSK Radiologist and in this Ultrasound plays
an invaluable role, being the preferred method of guidance for almost all interventions.
This talk will cover the subject under the following headings
1. Anatomy
2. Equipment and technique of examination
3. Pathologies around the elbow
4. US features of the above
5. Elbow intervention
6. Summary
The ultrasound imaging of the common pathology of the elbow such as medial and
lateral epicondylitis, collateral ligament evaluation, joint space and bursal
inflammations etc will be discussed along with diagnostic and therapeutic
interventional procedures.
At the end of the talk the audience will be able to have a considerable understanding of
elbow pathology and it’s ultrasound evaluation.
Role of CT in ankle and foot problems
Nuttaya Pattamapaspong M.D.
Department of Radiology, Faculty of Medicine,
Chiang Mai University, Chiang Mai, Thailand.
Abstract:
The ankle and foot are complex structures comprising of multiple bones, joints,
and soft tissue structures. Multiplanar and three-dimensional images which can
demonstrate anatomical structures are required in most of the ankle and foot problems.
Multidetector technology and post processing software have advanced computed
tomography (CT) to produce high quality multiplanar reformatted and threedimensional images. Currently, CT is necessary in preoperative assessment of complex
fractures of tibial pilon and calcaneus. CT helps demonstrate structural alteration from
coalition, neuropathic arthropathy, and malunion fracture. This talk will emphasize on
applications of CT in assessing complex fractures of the ankle and foot as well as review
the utility of CT in other ankle and foot problems. Practical issues in scanning
technique, image reconstruction, and interpretation will be discussed.
Pitfalls in musculoskeletal magnetic resonance imaging
Professor Wilfred CG Peh MBBS, MD, FRCP (Edin), FRCP (Glasg), FRCR
Senior Consultant and Head,
Department of Diagnostic Radiology,
Khoo Teck Puat Hospital, and
Clinical Professor, Yong Loo Lin School of Medicine,
National University of Singapore
Abstract:
The practice of musculoskeletal radiology has become increasingly complex, with
growing utilization of advanced imaging modalities. Magnetic resonance (MR) imaging
is a powerful diagnostic imaging tool that is currently used in daily practice for the
evaluation of a spectrum of musculoskeletal disorders. These applications include
trauma to structures such as bones, joints, tendons, ligaments, muscles and nerves, as
well as various diseases affecting these structures.
While the latest MR imaging machines are able to show a larger number of
musculoskeletal structures in more detail and with greater spatial resolution, a
downside is the increased detection of clinically-unsuspected normal anatomic variants
and generation of a variety of artifacts. Failure to recognize these anatomic variants and
imaging artifacts may lead to diagnostic error and misinterpretation, and potential
medicolegal problems. Inadequate imaging technique, lack of training/inexperience
and failure to correlate with other imaging findings, particularly radiographs, are other
potentially correctable pitfalls that may affect radiologists.
MR imaging artifacts may not only affect image quality, but may also simulate
pathological lesions. Artifacts may arise from patient motion or periodic motion, and
from various protocol errors producing saturation, wrap around, truncation, shading,
partial volume averaging and radiofrequency interference artifacts. Susceptibility
artifact occurs at interfaces with different magnetic susceptibilities and assumes special
importance with increasing use of metallic implants. Magic angle phenomenon is a
special type of MR imaging artifact.
In summary, recognition of various artifacts, variants and other potential pitfalls
encountered in musculoskeletal imaging should help the practising radiologist achieve
a more accurate diagnosis in daily clinical practice.
Vertebroplasty: Current Status, Future Directions and
Controversies
Peter L Munk MDCM, FRCPC, FSIR
Professor
Radiology, Vancouver General Hospital
Abstract:
Vertebroplasty was first designed in the 1980s as a minimally invasive percutaneous
treatment of vertebral hemagiomas and metastases. Subsequently vertebroplasty use
was later expanded allowing for treatment of painful osteoporotic compression
fractures. At present tens of thousands of these procedures are performed every year
all over the world. A large body of literature exists reviewing the technical issues in
performance of these procedures as well as documentation of their efficacy and
complications. Over the years modifications of the original technique have been devised
both for use in the spine as well as non spinal sites particularly the pelvis.
This lecture will briefly review the technique for performance of vertebroplasty and also
illustrate examples to cement injections outside the spinal axis (ie cemetoplasty). Some
of the variants of vertebroplasty which have been developed will be briefly discussed as
well as possible directions of future development.
With the publication of two highly controversial papers in 2009 doubts about the
efficacy of vertebroplasty emerged resulting in transient precipitous decline in the use
of this technique, which has since been reversed. The issues surrounding this
controversy will be reviewed.
MR Evaluation of the Heel Pain
Dr Raj Negi MD, DNB (Radiodiagnosis), FRCR (UK)
INHS Asvini, Colaba, Mumbai
Abstract :
Heel pain or calcaneodynia is a common and frequently disabling clinical complaint
which accounts for almost 15% of patients presenting to the primary health care
facilities. A variety of causes both osseous and soft tissues are attributed to this
complaint. MRI using its multiplanar capability, superior soft tissue contrast and lesion
characterization has emerged as a mainstay in imaging of clinically ambiguous cases.
Amongst the common known aetiologies the important ones are pertaining to the
plantar fascia (fasciitis, rupture), Achilles tendon (tendinitis, Haglund’s deformity),
calcaneum (trauma, infection, inflammation and tumor), bursae (inflammation), tarsal
tunnel (entrapment neuropathy) and heel plantar fat (infection, painful heel fat pad).
Each of these entities has specific imaging findings and in collaboration with the clinical
inputs is well adjudged on MRI examination.
The aim of this presentation is to outline the role of MRI in diagnosing the cause of heel
pain and thereby guide the clinician as to the line of treatment.
MRI of femoro-acetabular impingement: current
concepts
Remide Arkun,M.D.
Izmir, TURKEY
Femoroacetabular impingment (FAI) is a pathological entity which occurs when there
is a conflict between the proximal femur and the acetabular rim and can lead to chronic
symptoms of pain, reduce rate of motion in flexion, adduction and internal rotation of
the hip joint. FAI is the major cause of early osteoarthritis(OA) of the hip, especially in
young and active patients. Depending on clinical and radiographic findings, two types
of impingement are distinguished. While, predominant morphological abnormality
involves the femur in cam type FAI, predominant morphological abnormality involves
the acetabulum in pincer type FAI. Cam and pincer lesions lead to distinct patterns of
labral and chondral damage and long-standing impingement is likely a significant
cause of previously described idiopathic hip joint degeneration.
Cam type of impingement describes the femoral head and neck relationship as
aspherical or not perfectly round. This loss of roundness contributes to abnormal
contact between the femoral head and acetabulum. In case of cam FAI, the nonspherical
shape of the femoral head at the femoral head-neck junction and reduced depth of the
femoral waist leads to abutment of the femoral head-neck junction against the
acetabular rim. Pincer type of impingement describes the situation where the
acetabulum has too much coverage of the femoral head. This over-coverage typically
exists along the front-top rim of the acetabulum and limits the range of motion and
leads to a conflict between the acetabulum and the femur. This conflict results in the
labral cartilage being “pinched” between the rim of the acetabulum and the anterior
femoral head-neck junction. Most patients (86%) have a combination of both forms of
impingement, which is called “mixed pincer and cam impingement,” with only a
minority (14%) having the pure femoroacetabular impingement forms of either cam or
pincer impingement.
The role of imaging in FAI is to evaluate the hip for abnormalities associated with
impingement and to exclude arthritis, avascular necrosis, or other joint problems on
radiographs. Several imaging modalities such as conventional radiography, computed
tomography(CT) and magnetic resonance imaging (MRI) have been used to identify
the specific imaging findings of FAI. The diagnosis of FAI is based on the patient’s
clinical history and physical examination and is further supported by findings at
radiography, CT and MR imaging. It is important to identify the type of FAI and
describe anatomical changes because surgical treatment differs for each type.
Acetabular labrum, acetabular cartilage and femoral head cartilage are mainly affected
in patients with FAI. Articular cartilage and labrum is assessed better with MRI in
patients who have clinical and radiographic signs of FAI. It is important to know that
surgical treatment of FAI is only suitable in patients without advanced degenerative
changes and without extensive articular cartilage damage. The process of FAI is well
demonstrated with MR imaging. The most important role of preoperative MR imaging
in patients with FAI is to assess the exact extent of the damage already present within
the joint. MR arthrography is superior to MR imaging in the detection and staging of
acetabular labrum lesions.
In MR imaging, high resolution and high quality images are necessary to make accurate
assessment for labrum and cartilage lesions. Aside from standard axial, coronal and
sagittal planes, an oblique plane paralleling the femoral neck is useful in assessing the
anterior superior labrum. Alpha angle also can be measured from this plane. Using a
cutoff of 55 degrees may result in a more specific diagnosis of an abnormal femoral
head-neck offset. However, recent studies showed that alpha angle over 55 degrees also
can be seen asymptomatic subjects.
These examinations may show anterior and anterosuperior or anteroinferior acetabular
labral damage. Cartilage lesions were most commonly found at the anterosuperior part
of the acetabulum. The acetabular labrum, when damaged, shows increased signal on
T2-weighted images that extends to the articular surface. This increased signal can
either be well defined or ill defined as is seen in linear and degenerative tears,
respectively.
MR arthrography is considered the modality of choice for accurately determining the
location and extent of labral avulsion and cartilage lesions. MR arthrography is
considered the reference standard and clearly depicts the main diagnostic imaging
features of FAI, cartilage, and labral lesions. The advantage of MR arthrography over
nonarthrographic MR imaging is that the intraarticular contrast material distends the
joint, separates intraarticular structures, and provides internal contrast to delineate the
labrum and cartilage as distinct entities. Although the head-neck morphology could be
measured without intraarticular contrast, the associated cartilage and labral
abnormalities would be more difficult to see.
Imaging findings currently described for FAI have not proved to be specific for
diagnosing this disease process. Numerous studies have shown that a significant
percentage of asymptomatic volunteers demonstrate multiple imaging findings of FAI.
Correlation with symptoms and physical examination findings is paramount to
diagnosing FAI.
MR Imaging of the Menisci
Dr Richa Arora MD , FRCR, MMED
Assistant Professor
Nizams Institute of Medical Sciences
Hyderabad-500082
Abstract :
 Menisci are semilunar (C shaped) fibrocartilaginous structures composed of
collagen fibres arranged circumferentially and radial fibres extending from the
capsule between the circumferential fibres. They are important both structurally
and functionally and are involved in distribution of stresses over the articular
cartilage, absorption of shocks during axial loading, stabilization of knee in both
flexion and extension, minor contribution towards secondary stabilization after
cruciate ligament injuries and joint lubrication. MR imaging plays an important
role in diagnosing meniscal pathologies and MR of the knee is the most
frequently requested MR among all joints.
MRI Features Of Seronegetive Spondyloarthropathy
Dr. Sandeep Velicheti
Assistant professor,
Pinnamaneni Siddhartha Medical College.
Consultant radiologist & Diagnostic Neuro radiologist
Sentini hospital,
Abstract:
Early features of ankylosing spondylitis and other seronegetive arthropathy can be very
well demonstrated in MRI. Bilaterality and characteristic pattern of involvement at
synovial portion of S.I joint helps to differentiate from infection. Chronic changes are
evident by sclerotic signals which are seen well with CT scan and plain radiographs.
MRI is currently included in the diagnostic criteria of spondyloarthritis proposed by the
‘Assessment of Spondyloarthritis International Society’
Disco-vertebral junction which is also involved in the inflammatory process is
well detected in MRI. Apart from these, changes in the facet joints, enthesopathy or
enthesitis can be well depicted on MRI; these changes are very difficult to pick up in
plain radiographs. MRI changes precede years before it is seen in plain radiographs
Hybrid Imaging Applications in Musculoskeletal
Disorders
Seoung-Oh Yang, M.D.
Departments of Nuclear medicine, Asia Cancer Center (DIRAMS),
Busan, Korea (South).
Abstract:
Hybrid imaging (SPECT/CT, PET/CT, PET/MR) were introduced recently. PET/CT
offers a hardware solution for viewing functional anatomic images simultaneously.
FDG-PET imaging has been most commonly used to evaluate primary bone and soft
tissue tumors, metastases, myeloma. Due to low incidence of primary musculoskeletal
tumors only limited data are available to estimate the clinical usefulness of PET. FDGPET also been evaluated for monitoring treatment effects in patients with sarcomas.
Limitations of FDG-PET/CT are the differentiation of low grade malignancy from
benign tumors and relatively low sensitivity in detecting osteosclerotic metastasis. The
accuracy may be increased by using more specific tracer such as 18F-fluoride, 18FFMT(tyrosine) and 18F-FLT(thymidine). PET/CT obviously provides advantages in the
evaluation of musculoskeletal tumors with excellent capability of anatomic localization
and capability of whole body imaging.
SPECT/CT with the integration of CT and SPECT gantries has enhanced bone scan
by providing accurate lesion localization and characterization of equivocal and solitary
bone lesions. SPECT/CT has been proven to increase sensitivity and specificity of bone
scan. SPECT/CT should be applied whenever equivocal findings of planar bone
imaging occur. The key impact has been enhanced diagnostic confidence in the
differentiation of benign from malignant skeletal lesions made possible by accurate
localization of lesions to facet joints, vertebral bodies, or pedicles due to the exact
coregistration of CT and SPECT as well as consideration of sclerosis or lysis within the
lesion seen on CT. Several studies comparing planar, SPECT, and SPECT/CT in
equivocal lesions have demonstrated a substantial improvement in specificity with
SPECT/CT.
Whole-body PET/MRI imaging demonstrated a good image quality with near perfect
correlation of findings in comparison to PET/CT. Both local extent within the bone and
invasion into the adjacent muscles can be determined more accurately on PET/MRI
than on PET/CT. Although FDG PET/CT has been shown to be more accurate when
assessing the lung for metastases, MRI has been reported to have higher accuracy than
FDG-PET/CT when assessing the liver and the bone for distant metastases. Diffuse
metastatic bone marrow infiltration may be difficult to detect on PET imaging and is
typically overlooked on CT, but they can be detected reliably with MRI. Therefore,
PET/MRI will possibly prove of higher diagnostic accuracy than CT and PET/CT, and
can be expected to provide a more accurate TNM-stage. On the other hands, FDG
PET/MRI protocols will have to be designed individually for each tumor entity. DWI,
especially in precise co-registration with PET, offers increased the sensitivity of
metastases detection and promising opportunities for tumor therapy effect monitoring.
Therefore, adding DWI to an anatomically-oriented PET/MRI whole-body protocol
seems to be indispensable for staging purposes.
MRI appearances of the wrist and carpal ligaments: a
pictorial review
Dr Srikanth Narayanaswamy
Consultant Musculoskeletal Radiologist
Sakra World Hospital .
Abstract :
Chronic wrist pain can be related to carpal instability which is based on the integrity of
the wrist and carpal ligaments. Injury to these ligaments can be a source of pain with or
without associated instability. Adequate knowledge of anatomy of these structures
provides the foundation in making the accurate radiological diagnosis. Advancement of
technology has revolutionized the understanding of these complex structures. MRI
remains the modality of choice in investigating the wrist and carpal ligaments. In this
exhibit, we will provide a descriptive illustration of the MRI anatomy of the main wrist
and carpal ligaments.
MRI of Elbow Joint in Inflammatory Arthritis
Dr. Swati pacharne
Specialist Radiologist, NMC Hospital, DIP 1, Dubai
MD Radiodiagnosis, Mumbai, India.
Teaching points :
1. To describe the role of MRI of Elbow Joint in Inflammatory Arthritis.
2. To prove MRI is the superior modality for proper diagnostic evaluation of Elbow
Joint in Inflammatory Arthritis.
3. To describe the pitfalls & corrective methods of MRI of Elbow Joint for proper
diagnostic evaluation of Inflammatory Arthritis.
Subscapular injuries related to acromiohumeral
instability of shoulder impingement syndrome
Tae Yong Moon
Pusan National University Yangsan Hospital,
Yangsan, S. Korea
Objectives:
To evaluate the relation of subscapularis injuries with acromiohumeral instability of
shoulder impingement syndrome
Imaging of Pediatric Knee injuries
Suphaneewan Jaovisidha, MD
Professor of Radiology
Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
Abstract:
The knee is the joint that frequently injured because it is intrinsically unstable. The
curve surfaces of femoral condyles articulate with the flat proximal tibia. And because
of this anatomy, ligaments & menisci play a crucial role in knee stabilization
Children are susceptible to injuries because of numbers of developmental factors. The
first factor is lack of developed complex motor skills. The second is the open physes are
more vulnerable to stress than tendon, and they needs 4-5 times of force to tear the
tendon compare to avulse the physis. The third factor is musculoskeletal imbalance. The
limb length increases 1.4 times from age 6-14 but the limb mass increases by more than
3 times. The larger increase in mass forces the muscle to generate greater force to move
the limb, creating strain to the tendons, myotendinous junction (MTJ), and the physis.
Extra-articular soft tissue injuries comprise 82.7% of clinical diagnosis of knee injury in
children. The other diagnoses are patellar disorders (8.8%), intra-articular soft tissue
injuries (4.3%), overload/overuse injuries (3.2%), and fractures (1.1%).
Trauma in children often involves radiolucent structures & difficult to access on plain
radiographs, and magnetic resonance (MR) imaging has become an important modality
because it can show the physis, cartilage, meniscus & ligaments
Many diagnostic MR criteria in children are similar to those used in adult patients. The
content will emphasize on the differences. For example, kissing contusion, which is
marrow edema associated with anterior cruciate ligament (ACL) tear in adult, was
reported in children without ACL tear due to more laxity of ACL in this age group.
In children, chondral/osteochondral injury is more frequent than ACL and meniscus
injury. It was considered significant because it may predispose premature osteoarthritis,
and it may cause joint locking and pain due to the loose body.
Complications of physeal injuries consisted of growth arrest which directly
proportionate to increasing Salter-Harris number, angular deformity, leg length
discrepancy, bone bridging and then long term disability
Imaging of hip joint in children
Dr N.L.N.MOORTHY
Prof of radiology
Gandhi medical college/ hospital
Secunderabad INDIA
Abstract:
Diseases of hip joints are common in paediatric
age group . They include
developmental dysplasia of hip,perthes disease, septic arthritis, tuberculosis hip joint,
slipped capital femoral epiphysis, bone cyst, fibrous dysplasia, juvenile rheumatoid
arthritis etc. They usually present with limp,painful hip, irritability of joint .Imaging
plays a major role in making appropriate diagnosis. The radiological investigations
include plain radiography, (antero posterior and frog leg views), ultrasound, MRI and
CT scan . The various lesions that affect the hip joints in children are broadly classified
into
Congenital : developmental dysplasia of hip, congenital short femur, proximal focal
femoral deficiency
Developmental : Leg Calve Perthes disease, coxa valga, coxa vara
Inflammations: juvenile rheumatoid arthritis, dermatomyositis
Trauma: slipped capital femoral epiphysis, apophyseal injuries
Infections: transient synovitis, tuberculous arthritis, septic arthritis
Benign neoplasms : unicameral bone cyst, aneurysmal
bone cyst, esoniphilic
granuloma
Malignant neoplasm: lymphoma, leukemia, ewing’s sarcoma
Developmental dysplasia of the hip: Ultrasound is highly specific in the diagnosis and
shows a rounded acetabular roof and an alpha angle of less than 50%.
Proximal femoral focal deficiency: Plain radiographs show the osseous defects
Legg-Calve-Perthes disease: Though radiography is sensitive MRI is used in early
detection where the lesion appear as low T1 and High T2 signal intensity and with no
enhancement on contrast administration.
Transient synovitis : On imaging there may be joint space widening with hip effusion.
Juvenile rheumatoid arthritis: Ultrasound detects the presence of joint effusion. MRI
with contrast is very sensitive for assessing the soft tissue edema, proliferative
synovium. Slipped capital femoral epiphysis: Plain radiography shows widening ,
lucency and irregularity of the physis on the affected side.
The various imaging features of other conditions will be discussed.
Sclerosing Skeletal Dysplasias
Prof. Kakarla Subbarao
Emeritus Professor
Nizam’s Institute of Medical Sciences,
HYDERABAD.
Abstract:
Sclerosing bone dysplasias constitute a variety of abnormalities with a wide range of
clinical, genetic and imaging features. Conventional radiology plays a major role.
Several genes have been described and when disrupted cause, different types of bone
dysplasias. These include osteopetrosis, pycnodysostosis, osteopoikilosis, osteopathia
striata, Engelman dysplasia, dysosteosclerosis and Van Buchem. Melorrheostosis and
Ribbing disorders or non-heriditory. Knowledge of the radiological features is essential
for the diagnosis as histology does not help much. Acquired sclerosing skeletal
disorders are not included in this presentation.
Prof Kakarla Subbarao
MRI of the labroligamentous complex
Quek ST
Head and Senior Consultant, Department of Diagnostic Imaging,
National University Hospital
Clinical Director, Breast Screen Singapore Programme,
National University Health System
Abstract:
Shoulder injuries are increasingly encountered as a result of sporting activities due to
lifestyle changes. The assessment of patients with shoulder injuries include assessment
for instability which may result from injury to the dynamic or static stabilisers of the
shoulder joint. This talk reviews the anatomy of the gleno-labroligamentous complex (a
key component of the static stabilisers of the shoulder joint), the more common forms of
injuries involving the complex as well as some pitfalls in diagnosis.
Diagnosis of subtle bone erosions in digital
environment
Shigeru Ehara, M.D.
Morioka, Japan
1. Changes in treatment
Early application of DMARDs and new biological therapy, including anti TNF agents,
have significantly improved treatment outcome of rheumatoid arthritis. Objective of the
imaging diagnosis has shifted to early detection of subtle arthritic changes. In addition,
imaging diagnosis of early RA changes is currently performed in the digital
environment with limited spatial resolution. Among imaging studies, plain
radiography, including storage phosphor and flat panel detector (FPD) radiography, is
aimed to detect subtle bone erosion. Ultrasound is suited to detect superficial lesions,
particularly synovitis of surface small joints, and MR imaging is used to detect synovitis
and bone marrow changes in almost any locations.
2. Characteristics of current digital imaging system
Limited spatial resolution and high contrast resolution are characteristic in the current
digital system, compared with the conventional film-screen radiography. Thin cortex is
close to the limitation of spatial resolution of the digital system. Fine detail radiography
using fine-grain industrial film (e.g. Kodak M) used to be applied (Radiology 112:37), but
now it is not readily available. In currently used storage phospher radiography,
resolution is limited, < 2.5 lp/mm, compared to 3-8 lp/mm for conventional system. On
the other hand, exposure latitude is as high as 10,000:1 (30-40:1 in screen-film system).
FPD radiography is characterized by increased detective quantum efficiency, exposure
reduction of 50-75%, and improved contrast detectability (Radiology 231:506). Digital
tomosynthesis is currently used sectional imaging system with relatively low radiation
exposure with high spatial resolution, and it is suited to detect early arthritic changes
(Aoki).
3. Radiographic diagnosis of early or subtle RA
Early RA is defined as RA of less than 3 months after onset. Early or subtle signs
include surface erosion, soft tissue swelling, and subchondral bone resorption. Erosion
is highly specific for RA, and its types include marginal, subchondral, and pressure.
Surface erosion, another type, is partial wasting of subchondral lamina, which is close
to the limitation of resolution, 0.05-0.1 mm. Limitation of the resolution of current
system is similar, at 0.2-0.05 mm. Norgaard erosion is a small notch with sclerotic border
in asymptomatic population, and used to be considered a normal variation. However,
such small superficial erosion of proximal phalanx may be considered to be an early
sign of early RA (Br J Rad 53:63). Soft tissue swelling, another early change, depends on
contrast resolution, and it represents either joint effusion or synovial inflammation.
Subchondral bone resorption may be an early sign, but it is more commonly seen in
later stages.
4. Early detection of marrow lesion on MRI
Early imaging features of RA may lack radiographic findings. Bone marrow change,
only assessed on MR imaging, may be seen two years earlier (Østergaard). Detection and
distribution of early RA changes are assessed by MR imaging. Whole body and whole
hands MR images are used to detect bone marrow edema on T1W & T2W images and
synovitis on T2W and Gd-contrast images.
5. Conclusion
Overall performance of the digital system for early arthritis is comparable to, but not
better than, the conventional system. Continuous quality control of imaging system is
important to detect early and subtle arthritic changes in a reproducible manner.
Athletic Pubalgia, “Sports Hernia” and Anterior Pelvic
Pain
Dr THAM Seng Choe
Consultant Radiologist
Mount Elizabeth Novena Hospital
Singapore
Abstract:
Athletic pubalgia, also known as “sports hernia”, is not an uncommon cause of anterior
pelvic pain in athletes. It is associated with sports that require hip flexion with trunk
rotations such as soccer or hockey.
The adductor longus and rectus abdominis muscles attach at the pubic bone. An
imbalance in
these antagonistic muscles is postulated to contribute to athletic pubalgia. The adductor
longus - rectus abdominis aponeurosis is frequently injured as a result.
MRI is typically the study of choice for athletic pubalgia. Due to the unique anatomy of
the involved structures, proper understanding of the anatomy and dedicated imaging
of this region is required.
Careful and proper evaluation should be made as other causes, such as hip pathologies,
may not only mimic athletic pubalgia but also occur in concurrence with it. Accurate
diagnosis is important for successful treatment and faster return to play for the athlete.
The comparison of tomosynthesis, computed
tomography and X-rays in the imaging of peri-prosthesis
after THA
Ma yimin, Su yongbin, Shao Hongyi et al,
Department of radiology,
Jishuitan hospital, Beijing, 100035
China
Abstract:
Objective - To compare the definition of structures around the prosthesis among
tomosynthesis (TOMOS), computed tomography(CT), and digital radiography(DR).
Material and Methods Twenty consecutive patients (mean age, 61.0±10.4 years; range,
36–82 years) with THA referred for TOMOS, CT and DR hip imaging. Three senior
attending radiologists independently evaluated the definition of acetabulum region,
prosthesis, and proximal femur region, in TOMOS, CT and DR images. Scores
calculated would be analysed via Generalized Estimating Equations. Results TOMOS’s
image quality of the acetabulum and proximal femur region was rated significantly
superior to CT’s(P <0.001). DR’s image definition was significantly better than CT’s(P
=0 - 0.0077).
Conclusion: Compared to CT, TOMOS and DR imaging techs can reduce artefacts
caused by prothesis, which made the image definition better.
Ultrasound evaluation of lower limb nerves
Dr.Srinadh Boppana
Consultant radiologist
Kamineni hospitals, L.B.nagar,
Hyderabad
Abstract:
Peripheral neuropathies are relatively common clinical disorders. They can be divided
into compressive (entrapment) and non-compressive neuropathies based on their
etiology. Entrapment or compressive neuropathies are important and widespread
debilitating clinical problems, especially in patients with predisposing occupations or
with certain medical disorders.
Although nerves may be injured anywhere along their course, peripheral nerve
compression is often caused by mechanical dynamic compression of a short segment of
a single nerve at a specific site most frequently as it passes through a fibro-osseous
tunnel, or an opening in fibrous or muscular tissue. High-resolution Ultrasound is a
simple, cost effective diagnostic tool that allows direct imaging of the involved nerves,
identification of the underlying cause and severity of the compression. A spectrum of
extrinsic causes of entrapment, such as tenosynovitis, ganglia, soft-tissue tumors, bone
and joint abnormalities, and anomalous muscles, can also be diagnosed with
ultrasound.
ISS ROP Teaching Programme
Mark J. Kransdorf, M.D.
Consultant
Department of Radiology
Mayo Clinic.
Infections and inflammations of the foot: multimodality
approach
Dr. Ram Mohan Vadapalli
Consultant Radiologist,
Vijaya Diagnostics (3T MRI and 128 slice scanner) at Hyderabad.
Foraminal epdiural injections for low back pain
Dr Tuhin Sikdar
Consultant Radiologist at Princess Alexandra Hospital in Harlow, UK.
Imaging of SLAC wrist
Dr.Varaprasad.N.Vemuri MD
Chief Consultant
Global Multispecialty Hospital
Vijayawada , AP
MRI of SLAP lesions
Dr Abhimanyu B. Kelkar
Director,
P.D.S. CT scan centre and omega mri centre.,
Pune.
Ultrasound of brachial plexus
Upper limb nerves
Carlo Martinoli, MD
Associate Professor of Radiology,
University of Genoa.
Role of US in the neonatal spine
Dr. T.L.N.Praveen
Director and Consultant,
Abhishek’s Institute Of Imageology, Hyderabad,
Andhra Pradesh, India
Ultrasound imaging of elbow – technique and
Evaluation
Prof. P.K. Srivastava
Professor Whole Body CT Scan and Ultrasound
Department of Radiotherapy
K.G.M.U.
Moderator for shoulder
Heung Sik Kang
Professor of Radiology
Seoul National University College of
Medicine, Seoul, Korea.
DR. Swati Pawar
Director and Consultant Radiologist
Usha Diagnostic and Scan Centre, Airoli.